Provider Demographics
NPI:1285644526
Name:ABRAHAM, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ABRAHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:PHILIP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:350 WINN WAY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2106
Mailing Address - Country:US
Mailing Address - Phone:404-508-1177
Mailing Address - Fax:404-508-9640
Practice Address - Street 1:350 WINN WAY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2106
Practice Address - Country:US
Practice Address - Phone:404-508-1177
Practice Address - Fax:404-508-9640
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056399208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA335852OtherWELLCARE
GA335854OtherWELLCARE
GA2947741OtherCIGNA
GA335853OtherWELLCARE
GA52704327OtherBCBS
GA10045386OtherAMERIGROUP
GA236258795AMedicaid
GA236258795CMedicaid
GA7673845OtherAETNA
GA236258795BMedicaid
GA236258795DMedicaid
GA2625722OtherUHC
GA335588OtherWELLCARE
GA236258795BMedicaid
GA236258795CMedicaid